Geriatric Pain Management

Key Points

Evidence-based approaches to assessment and management can help older adults thrive and have a good quality of life.
A wide range of validated tools are available to assess pain in older adults, including individuals with cognitive impairment.
A multimodal, comprehensive approach to pain management is imperative.
Providers need to be aware of and work to address barriers that often occur in assessing and managing pain in this age group, to physical and cognitive impairments as well as social and cultural issues.
The full range of available pharmacologic, non-pharmacologic pain management and coping approaches should be considered.
Providers are strongly encouraged to support older patients’ efforts to become active participants in their own care.

Introduction

The global population is aging rapidly, with demographic shifts resulting in the proportion of adults ages over 65 years and above significantly increasing globally from 6.1% to 8.8%. The rising prevalence of chronic conditions, of which persistent pain is a common and distressing symptom, is strongly associated with advancing age. Multimorbidity, the presence of three or more interacting chronic conditions, is a major contributor to persistent pain. Persistent pain, which exists beyond the expected healing time, often has no identifiable physical cause, and bothersome pain afflicts 52.9% or 18.7 million older adults. In nursing home residents, Lapane and colleagues found that 27.9% reported mild pain, 46.6% moderate pain, and 25.6% reported severe pain. Besides increasing age, risk factors associated with the development of persistent pain include sex, as women are more likely to report greater persistent pain than men, low income, mental health conditions such as depression and anxiety, and obesity. Prevalent causes of persistent pain in older adults are osteoarthritis, cancer, injuries/falls, chronic low back pain, and diabetes (i.e. diabetic neuropathy).

Conditions such as frailty and the residual effects of emerging health threats like that of communicable diseases such as Ebola and coronavirus-2 (SARS-CoV-2; known as COVID-19) may increase the risk and burden of chronic pain, especially in older adults who make up 80% to 95% of all COVID-19 fatalities in the United States and Europe, respectively. In fact, some speculate that COVID-19 will indeed increase chronic pain overall in the general population citing infections, inflammation, and psychological triggers as underlying drivers. This will likely result in new challenges in effectively managing multiple types of pain in older adults and perhaps necessitate multi-disciplinary rehabilitation and implementation of COVID-19 pain guidelines.

Unrelieved persistent pain in later life has many debilitating consequences, including psychological distress, social isolation, impaired sleep quality, physical disability, increased fall risk, and loss of independence. ^, Optimizing pain management is important, but obstacles to the identification, assessment, and management of pain underscore the importance of providing close attention to older patients. Consideration of an older adult’s health, functional capacities, and cognition are essential in relation to the patient’s ability to reliably report pain, and when formulating a pain management plan where they can engage in their care. This chapter provides the reader with an overview of the most current perspectives on the assessment and management of persistent pain in older adults and describes challenges healthcare providers may encounter when delivering pain care to older persons.

Barriers to Successful Pain Management in the Older Patient

Physiologic and Sensory Impairments

Anatomic and physiologic changes normally observed as part of the aging process are progressive, and concomitant injury or disease can rapidly worsen the health status of the older individual. Changes in pain transmission, tolerance, and threshold can decrease the speed of processing nociceptive stimuli and thus reduce older adults’ ability to sense and respond to early pain stimuli. Therefore older adults may have a greater susceptibility to burns and other injuries such as lacerations because they are not as likely to sense the initial pain and do not respond (e.g. removing hand) as quickly as younger adults. These alterations may reflect aging-associated reductions in peripheral intraepidermal nerve fiber density and small fiber neuropathy and contribute to sensory losses and pain. Additionally, sensory impairments are common among older adults and can negatively impact the management of pain. Visual impairments such as cataracts, macular degeneration, and diabetic retinopathy that can make it difficult to read prescription labels or participate in recommended exercise programs. Use of good lighting in patient exam rooms, asking older patients to wear eyeglasses, and providing reading materials in large font can help mitigate the negative impact of poor vision on pain care. Hearing impairments are also common. Handheld amplifiers, speaking slowly while facing the older patient directly to allow for lip reading, and providing written instructions can help to decrease the negative impact of hearing loss when managing pain among older adults with hearing deficits.

Cognitive Impairment

Cognitive deficits are common in later life but remain under recognized and under treated. Although a recent study suggests pain treatment in those with moderate-severe dementia has improved, 45% of residents experienced moderate to severe pain and still less likely to receive pain treatment than cognitively intact residents. Numerous barriers exist to provide appropriate analgesia to this group, both at the patient and provider levels. Communication is a major challenge to both assessing and managing pain in this patient population, and cognitively impaired older patients tend to under report pain. Manifestation of pain in cognitively impaired older patients can also vary, from behavioral disturbances, such as lethargy and physical aggression, to more expected reactions such as groaning and grimacing. Cognitive impairment creates additional challenges to assessing pain in older adults. As the severity of cognitive impairment increases, a patient’s ability to self-report pain diminishes, particularly if experiencing multiple cognitive issues such as delirium, agitation, and dementia. ^,

Caregiving

As the prevalence of pain increases among older adults, so does the demand for caregivers, especially informal caregivers. Informal caregivers and unpaid caregivers, such as family members, relatives, friends, and partners, who take care of loved ones are playing a greater role in their managing the older adult’s condition and symptoms. One of the most challenging tasks for caregivers is the management of pain, and caregivers encounter a variety of barriers related to the management of their loved one’s pain, including lack of education, ineffective communication with providers, and their own wellbeing. Attention to these needs is essential as the caregiver could be a great asset or adjunct to pain management across the life span. Adequate pain management skills training and education of caregivers can improve patient outcomes.

Beliefs and Attitudes About Aging and Pain

Certain beliefs that older adults and providers have about pain and pain treatments may negatively influence their expectations, behaviors, and decisions regarding treatment recommendations and engagement and/or adherence. As noted, many older individuals consider pain as a natural part of getting older, and rather than seek care, often consider it as something to bear. Beliefs such as these can lead to stoicism or acceptance of the status quo. Although relatively little research has examined whether these beliefs are associated with specific health behaviors, beliefs can negatively affect an older patient’s willingness to seek treatment or adhere with a recommended treatment plan. Prior research has also shown that some older adults endorse beliefs and fears(e.g. addiction and dependence) about pain medications that decrease their willingness to engage in or adhere with pharmacologic interventions. These concerns may also be voiced by older patients’ caregivers, often a spouse or an adult child. Thus some healthcare providers may be more reluctant to prescribe opioid medications for older patients with non-cancer pain because of a fear of causing patient harm. Older adults with pain who endorse this belief report minimizing medication use except when the pain is “very bad.” Others show that severe pain is associated with opioid and psychotropic medication use in older adults. Providers should be diligent in ascertaining these beliefs during regular clinical encounters and provide research-based education to counter ageist misconceptions. Within a pain management context, this would mean asking patients open questions about their views on the origins and cause of pain, the meaning and impact of pain, their views about treatment and treatment goals, and educational needs.

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